Sara Shaw

The organising vision for telehealth and telecare : discourse analysis

Objective To (1) map how different stakeholders understand telehealth and telecare technologies and (2) explore the implications for development and implementation of telehealth and telecare services. Design Discourse analysis. Sample 68 publications representing diverse perspectives (academic, policy, service, commercial and lay) on telehealth and telecare plus field notes from 10 knowledge-sharing events. Method Following a familiarisation phase (browsing and informal interviews), we studied a systematic sample of texts in detail. Through repeated close reading, we identified assumptions, metaphors, storylines, scenarios, practices and rhetorical positions. We added successive findings to an emerging picture of the whole. Main findings Telehealth and telecare technologies featured prominently in texts on chronic illness and ageing. There was no coherent organising vision. Rather, four conflicting discourses were evident and engaged only minimally with one anothers arguments. Modernist discourse presented a futuristic utopian vision in which assistive technologies, implemented at scale, would enable society to meet its moral obligations to older people by creating a safe ‘smart’ home environment where help was always at hand, while generating efficiency savings. Humanist discourse emphasised the uniqueness and moral worth of the individual and tailoring to personal and family context; it considered that technologies were only sometimes fit for purpose and could create as well as solve problems. Political economy discourse envisaged a techno-economic complex of powerful vested interests driving commodification of healthcare and diversion of public funds into private business. Change management discourse recognised the complicatedness of large-scale technology programmes and emphasised good project management and organisational processes. Conclusion Introduction of telehealth and telecare is hampered because different stakeholders hold different assumptions, values and world views, ‘talk past’ each other and compete for recognition and resources. If investments in these technologies are to bear fruit, more effective inter-stakeholder dialogue must occur to establish an organising vision that better accommodates competing discourses.

Linguistic Ethnography: Collecting, Analysing and Presenting Data

Ethnography and Language Linguistic Ethnography Data in Linguistic Ethnography Doing Research in Linguistic Ethnography: Building the Case Case study one: Reflexivity, voice and representation in linguistic ethnography Case study two: Researching feedback conferences in pre-service teacher training Case study three: Ethnography and the workplace Case study four: Ethnography, language and healthcare planning Practical Issues in Linguistic Ethnographic Research Empiricism, ethics and impact Transcription, translation and technology Writing up: genres, writer voice, audience Ways forward

Comparative analysis of health policy implementation

Documentary analysis has been widely used in the comparative analysis of health care policy implementation in England. However, the value of the method is rarely debated, and the process whereby it is carried out rarely described in detail, or justified. Documentary analysis has obvious appeal. Documents may be the only source of data at an early stage of a policy innovation. They also present none of the problems (practical, ethical, interactive) of human subjects of research, and can provide a useful supplement to data collected from human subjects by other means. However, official documents are likely to be partial or superficial, representing aspirations rather than realities. The scope for analysis is therefore limited. Analysis may also tend to be positivist in philosophy, taking at face value the ‘apparent’ meanings of texts. It will be argued in this article, however, that a more interpretative analysis is also possible, when implied assumptions or underlying ideologies are identified and discussed. Thus, in the case of policy documents in the NHS, analysis may focus on one or more of three layers of meanings: those which are overt and explicit in the document; those which reflect the rhetoric of the policy environment and the governments intentions; and, those which reflect the ideology, usually implicit, underpinning policies at local and/or national level.

Commissioning healthcare for people with long term conditions: the persistence of relational contracting in England's NHS quasi-market.

BackgroundSince 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market.MethodsWe studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents.ResultsIn contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach.ConclusionsOur findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.

Reaching the parts that other theories and methods can’t reach: How and why a policy-as-discourse approach can inform health-related policy

This article illustrates how conceptualizing policy-as-discourse offers opportunities for those with a vested interest in policy to ‘reach the parts that other theories and methods can’t reach’. First, it explores the dialogical relationship between theory and method in the context of policy analysis, summarizing contemporary writing on conceptualizing and analysing policy and drawing on the work of Bacchi to describe the theoretical underpinnings of three different policy representations along with methodological corollaries, research practices and disclosures about the world that flow from each. This involves reflecting on three different answers to the question ‘what is policy?’: considering how policy might be conceptualized and analysed under each and narrating the kind of research stories that emerge. Second, the article focuses on one of Bacchi’s representations — policy-as-discourse — to provide readers with a case study of this dialogical relationship and drawing on published research exploring the development of primary care research policy to illustrate what elements of discursive policy analysis might look like. Last, the article concludes by reflecting on the ways in which such an approach may (and may not) prove valuable in analysing health-related policy.

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

Background Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs. Conclusions Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Discourse analysis: what is it and why is it relevant to family practice?

This paper aims to illustrate what discourse analysis is and how it can contribute to our understanding of family practice. Firstly, we describe what ‘discourse analysis’ is, mapping the discourse analysis terrain by discussing four studies relevant to primary care to illustrate different methodological approaches and key concepts. We then address the practicalities of how to actually do discourse analysis, providing readers with a worked example using one particular approach. Thirdly, we touch on some common debates about discursive research. We conclude by advocating that researchers and practitioners take up the challenge of understanding, utilizing and extending the field of discourse studies within family practice.

Virtual online consultations: advantages and limitations (VOCAL) study.

Introduction Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations. Methods To explore the advantages and limitations of video consultations, we will conduct in-depth qualitative studies of real consultations (microlevel) embedded in an organisational case study (mesolevel), taking account of national context (macrolevel). The study is based in 2 contrasting clinical settings (diabetes and cancer) in a National Health Service (NHS) acute trust in London, UK. Main data sources are: microlevel—audio, video and screen capture to produce rich multimodal data on 45 remote consultations; mesolevel—interviews, ethnographic observations and analysis of documents within the trust; macrolevel—key informant interviews of national-level stakeholders and document analysis. Data will be analysed and synthesised using a sociotechnical framework developed from structuration theory. Ethics approval City Road and Hampstead NHS Research Ethics Committee, 9 December 2014, reference 14/LO/1883. Planned outputs We plan outputs for 5 main audiences: (1) academics: research publications and conference presentations; (2) service providers: standard operating procedures, provisional operational guidance and key safety issues; (3) professional bodies and defence societies: summary of relevant findings to inform guidance to members; (4) policymakers: summary of key findings; (5) patients and carers: ‘what to expect in your virtual consultation’. Discussion The research literature on video consultations is sparse. Such consultations offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (eg, they may be more cost-effective), but fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges. We anticipate that this study will contribute to a balanced assessment of when, how and in what circumstances this model might be introduced.

The work of commissioning: a multisite case study of healthcare commissioning in England's NHS

Objective To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change. Design Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings. Participants Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives. Setting Three ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012. Results Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems. Conclusions Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.

The view from nowhere? How think tanks work to shape health policy

Think tanks seek to shape the business of government by offering policy expertise in a number of areas, including health care. This expertise tends to be presented as ‘the view from nowhere’ – independent, value-neutral expertise that can inform policy. We challenge this view by examining what ‘independence’ means and how it is performed. We present an interpretive policy analysis of data collected from four UK-based think tanks that have sought to influence health policy. Our analysis demonstrates how a sample of healthcare think tanks publicly positioned themselves as ‘independent’ organizations. They drew on technocratic health planning discourse to emphasize a range of knowledge-related activities, artifacts and instrumental language that, informants suggested, allowed them to feed emerging evidence into policy and improve health services. Such positioning seemed to provide them with legitimacy in the eyes of decision makers. A parallel set of think tank activities (e.g., meetings with parliamentarians) took place ‘back-stage’ and focused on influencing health policy and, in the context of recent proposals to reform the English National Health Service, lending broad though not unqualified support to government proposals to extend market principles in health care. Informants appeared to seek to neutralize their presentation of such ‘back-stage’ influencing through a range of discursive strategies.